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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord. 41549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. WATER SUPPLY <br /> Is Water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public crater: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results - Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSOUTTO OR VrQ TOR )'[21NTTAL <br /> State possible vector potential & necessary control: <br /> 5. TOTLET/BATH FACILITES <br /> No. ec location existing: Additional <br /> facilities needed <br /> 6. PREVTonS CPLRATTON HTSTORy <br /> 7 . GENERAL SANITATTON <br /> State any problems not previously noted: <br /> 3 . POPULATION DENSTTY <br /> Appx. No. People per eq. mi. <br />